Recommendations

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Recommendations

The CSB issues safety recommendations to prevent the recurrence or reduce the likelihood or consequences of similar incidents or hazards in the future. Recommendations are issued to a variety of parties, including government entities, safety organizations, trade unions, trade associations, corporations, emergency response organizations, educational institutions, and public interest groups. Recommendations are published in CSB reports and are closed only by vote of the Board. The CSB tracks all recommendations and communicates regularly with recommendations recipients to ensure that the recommended corrective actions are implemented.

Modify ANSI Z400.1 American National Standard for Hazardous Industrial Chemicals--Material Safety Data Sheets to recommend that MSDSs include information on: - combustible dust hazards, safe handling practices, and references to relevant fire codes in MSDS; - hazard information about the by-products of materials that may generate combustible dusts due to processing or handling; - identification of combustible dust hazards and selection of physical properties to include in MSDS.

Open - Unacceptable Response/No Response Received (O - UR) - Recipient responds by expressing disagreement with the need outlined in the recommendation. The Board believes, however, that there is enough supporting evidence to ask the recipient to reconsider.

Revise the Hazard Communication Standard (HCS) (1910.1200) to: - Clarify that the HCS covers combustible dusts, including those materials that may reasonably be anticipated to generate combustible dusts through downstream processing or handling. - Require Material Safety Data Sheets (MSDSs) to include the hazards and physical properties of combustible dusts, as well as clear information on safe handling practices and references to relevant consensus standards.

Communicate to the United Nations Economic Commission for Europe (UNECE) the need to amend the Globally Harmonized System (GHS) to address combustible dust hazards by: - defining combustible dusts, - specifying the hazards that must be addressed in chemical information sheets, and - addressing the physical properties that must be included on a chemical information sheet pertinent to combustible dusts.

Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.

2006-1-H-5

While a standard is being developed, identify manufacturing industries at risk and develop and implement a national Special Emphasis Program (SEP) on combustible dust hazards in general industry. Include in the SEP an outreach program focused on the information in the Safety and Health Information Bulletin (SHIB), Combustible Dust in Industry: Preventing and Mitigating the Effects of Fire and Explosions.

Enact a Tentative Interim Amendment as well as permanent changes to the National Fuel Gas Code (NFPA 54/ANSI Z223.1) to require that during the purging of fuel gas piping at industrial, commercial, and public facilities:(a) Purged fuel gases shall be directly vented to a safe location outdoors, away from personnel and ignition sources

(b) If it is not possible to vent purged gases outdoors, purging gas to the inside of a building shall be allowed only upon approval by the authority having jurisdiction of a documented risk evaluation and hazard control plan. The evaluation and plan shall establish that indoor purging is necessary and that adequate safeguards are in place such as:

• Evacuating nonessential personnel from the vicinity of the purging;
• Providing adequate ventilation to maintain the gas concentration at an established safe level, substantially below
the lower explosive limit; and

• Controlling or eliminating potential ignition sources(c) Combustible gas detectors are used to continuously monitor the gas concentration at appropriate locations in the vicinity where purged gases are released

(d) Personnel are trained about the problems of odor fade and odor fatigue and warned against relying on odor alone for detecting releases of fuel gases

Enact a Tentative Interim Amendment as well as permanent changes to the National Fuel Gas Code (NFPA 54/ANSI Z223.1) to require that during the purging of fuel gas piping at industrial, commercial, and public facilities:(a) Purged fuel gases shall be directly vented to a safe location outdoors, away from personnel and ignition sources

(b) If it is not possible to vent purged gases outdoors, purging gas to the inside of a building shall be allowed only upon approval by the authority having jurisdiction of a documented risk evaluation and hazard control plan. The evaluation and plan shall establish that indoor purging is necessary and that adequate safeguards are in place such as:

• Evacuating nonessential personnel from the vicinity of the purging;
• Providing adequate ventilation to maintain the gas concentration at an established safe level, substantially below
the lower explosive limit; and

• Controlling or eliminating potential ignition sources(c) Combustible gas detectors are used to continuously monitor the gas concentration at appropriate locations in the vicinity where purged gases are released

(d) Personnel are trained about the problems of odor fade and odor fatigue and warned against relying on odor alone for detecting releases of fuel gases

Open - Unacceptable Response/No Response Received (O - UR) - Recipient responds by expressing disagreement with the need outlined in the recommendation. The Board believes, however, that there is enough supporting evidence to ask the recipient to reconsider.

Develop and implement a near-miss reporting and investigation policy that includes the following at a minimum:

Ensure facility-wide worker participation in reporting all near-miss events and operational disruptions (such as significant iron powder accumulations, smoldering fires, or unsafe conditions or practices) that could result in worker injury.

Ensure that the near-miss reporting program requires prompt investigations, as appropriate, and that results are promptly circulated throughout the Hoeganaes Corporation.

Establish roles and responsibilities for the management, execution, and resolution of all recommendations from near-miss investigations

Ensure the near-miss program is operational at all times (e.g. nights, weekends, holiday shifts).

Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.

Open - Unacceptable Response/No Response Received (O - UR) - Recipient responds by expressing disagreement with the need outlined in the recommendation. The Board believes, however, that there is enough supporting evidence to ask the recipient to reconsider.

Open - Unacceptable Response/No Response Received (O - UR) - Recipient responds by expressing disagreement with the need outlined in the recommendation. The Board believes, however, that there is enough supporting evidence to ask the recipient to reconsider.

Revise the Combustible Dust National Emphasis Program (NEP) to add industry codes for facilities that generate metal dusts (e.g., North American Industrial Classification System, NAICS, code 331111 Iron and Steel Mills, and other applicable codes not currently listed). Send notification letters to all facilities nationwide under these codes to inform them of the
hazards of combustible metal dusts and NEP coverage.

Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.

Revise the state-adopted Dust National Emphasis Program (NEP) to add industry codes for facilities that generate metal dusts (e.g., North American Industrial Classification System, NAICS, code 331111 Iron and Steel Mills, and other applicable codes not currently listed). Send notification letters to all facilities statewide under these codes to inform them of the
hazards of combustible metal dusts and NEP coverage.

Publish an offshore exploration and production safety standard for the identification and effective management of safety critical elements (SCEs)— technical, operational, and organizational— with the goal of reducing major accident risk to As Low As Reasonably Practicable (ALARP), including but not limited to:
a. development and implementation of a SCE management system that includes the minimum necessary “shall” requirements in the standard to establish and maintain effective safety barriers to prevent major accidents;
b. methodologies for (1) the identification of SCEs and (2) the development of performance standards of each SCE, including its functionality, availability, reliability, survivability, and interactions with other systems;
c. establishment of assurance schemes for continuous active monitoring of all identified SCEs throughout each SCE’s lifecycle;
d. fulfillment of independent verification requirements and use of those verification activities to demonstrate robustness of the SCE management process;
e. development of process safety key performance indicators pertaining to the effective management of SCEs to drive continuous improvement.

Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.

2010-10-I-OS-4

Revise Blowout Preventer Equipment System for Drilling Wells (API Standard-53, 4th edition) to establish additional testing or monitoring requirements that verify the reliability of those individual redundant blowout prevention systems that are separate from the integrated system tests currently recommended.

Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.

Augment 30 C.F.R §250 Subpart S to require the responsible parties, including the lessee, operator, and drilling contractor, to effectively manage all safety critical elements (SCEs)— technical, operational, and organizational—thereby ensuring their effective operation and reducing major accident risk to As Low As Reasonably Practicable (ALARP). At a minimum, require the following improvements:

a. Written identification of all safety critical elements for offshore operations through hazard analysis. This list will be made available for audits and inspections performed by the responsible parties, external entities (e.g., independent competent parties, third-party auditors), and the regulator, and it will be shared among the lessee, operator, and drilling contractor. Identifying all safety critical elements shall ensure the establishment and maintenance of effective safety barriers to prevent major accidents;

b. Documented performance standards (as defined in Section 5.2 of the CSB Macondo Investigation Report Volume 2) describing the required performance of each SCE, including its functionality, availability, reliability, survivability, and interactions with other systems;

c. Augmentation of 30 C.F.R §250.1916 to include requirements for all responsible parties, including contractors, to conduct monitoring for continuous active assurance of all identified SCEs through each SCE’s lifecycle (as described in Section 5.0 of the CSB Macondo Investigation Report Volume 2);

d. Documented independent verification scheme for the identified SCEs reported to and subject to review by the regulator (as described in Section 5.5 of the CSB Macondo Investigation Report Volume 2), where:

1. the independent party meets BSEE criteria that guarantees its competence and independence from the company or facility for which it is providing verification;
2. the independent verification occurs prior to commencement of the offshore drilling or production activity and periodically, as defined by BSEE;
3. all resulting assessments of the independent verification activities will be tracked in a formal records management system; and
4. corrective action shall be taken to address negative verification findings and non-compliance. Verified noncompliance shall be tracked by the responsible party as a process safety key performance indicator and be used to drive continuous improvement.

Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.

2010-10-I-OS-2

Publish safety guidance to assist the responsible parties in fulfillment of regulatory obligations stipulated in R1 for the identification and effective management of safety critical elements (SCEs)—technical, operational, and organizational— with the goal of reducing major accident risk to As Low As Reasonably Practicable (ALARP), including but not limited to each of the identified minimum requirements (See R1, items a-d).

Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.

Revise American Petroleum Institute API RP 941: Steels for Hydrogen Service at Elevated Temperatures
and Pressures in Petroleum Refineries and Petrochemical Plants to:

a. Clearly establish the minimum necessary “shall” requirements to prevent HTHA equipment failures using a format such as that used in ANSI/AIHA Z10-2012, Occupational Health and Safety Management Systems;

b. Require the use of inherently safer materials to the greatest extent feasible;

Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.

a. Clearly establish the minimum necessary “shall” requirements to prevent HTHA equipment failures using a format such as that used in ANSI/AIHA Z10-2012, Occupational Health and Safety Management Systems;

b. Prohibit the use of carbon steel in processes that operate above 400 ºF and greater than 50 psia hydrogen partial pressure; and

Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.

Revise the Chemical Accident Prevention Provisions under 40 CFR Part 68 to require the documented use
of inherently safer systems analysis and the hierarchy of controls to the greatest extent feasible when
facilities are establishing safeguards for identified process hazards. The goal shall be to reduce the risk of major accidents to the greatest extent practicable, to be interpreted as equivalent to as low as reasonably practicable (ALARP). Include requirements for inherently safer systems analysis to be automatically triggered for all management of change, incident investigation, and process hazard analysis reviews and recommendations, prior to the construction of a new process, process unit rebuilds, significant process repairs, and in the development of corrective actions.

Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.

2010-08-I-WA-2

Until Recommendation 2010-08-I-WA-R1 is in effect, enforce through the Clean Air Act’s General Duty
Clause, section 112(r)(1), 42 U.S.C.§7412(r)(1) the use of inherently safer systems analysis and the
hierarchy of controls to the greatest extent feasible when facilities are establishing safeguards for
identified process hazards.

Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.

2010-08-I-WA-3

Develop guidance for the required use of inherently safer systems analysis and the hierarchy of controls for enforcement under 40 CFR Part 68 and the Clean Air Act’s General Duty Clause, section 112(r)(1),42 U.S.C. §7412(r)(1).

Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.

2010-08-I-WA-4

Effectively participate in the Tesoro Anacortes Refinery process safety culture survey oversight committee as recommended under recommendation 2010-08-I-WA-R15. Incorporate the expertise of process safety culture experts in the development and interpretation of the safety culture surveys. Ensure the effective participation of the workforce and their representatives in the development of the surveys and the implementation of corrective actions.

Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.

Based on the findings in this report, augment your existing process safety management regulations for
petroleum refineries in the state of Washington with the following more rigorous goal-setting attributes:

a. A comprehensive process hazard analysis written by the company that includes:

i. Systematic analysis and documentation of all major hazards and safeguards, using the hierarchy of controls to reduce those risks to as low as reasonably practicable (ALARP);

ii. Documentation of the recognized methodologies,rationale and conclusions used to claim that safeguards intended to control hazards will be effective;

iii. Documented damage mechanism hazard review conducted by a diverse team of qualified personnel. This review shall be an integral part of the Process Hazard Analysis cycle and shall be conducted on all PSM-covered process piping circuits and process equipment. The damage mechanism hazard review shall identify potential process damage mechanisms and consequences of failure, and shall ensure effective safeguards are in place to control hazards presented by those damage mechanisms. Require the analysis and incorporation of applicable industry best practices and inherently safer design to the greatest extent feasible into this review; and

iv. Documented use of inherently safer systems analysis and the hierarchy of controls to the greatest extent feasible in establishing safeguards for identified process hazards. The goal shall be to drive the risk of major accidents to As Low As Reasonably Practicable (ALARP). Include requirements for inherently safer systems analysis to be automatically triggered for all Management of Change and Process Hazard Analysis reviews, prior to the construction of new processes, process unit rebuilds, significant process repairs, and in the development of corrective actions from incident investigation recommendations.

c. Required preventative audits and preventative inspections by the regulator;

d. Require that all safety codes, standards, employer internal procedures and recognized and generally
accepted good engineering practices (RAGAGEP) used in the implementation of the regulations contain adequate minimum requirements;

e. Require an increased role for workers in management of process safety by establishing the rights and responsibilities of workers and their representatives on health and safety-related matters, and the election of safety representatives and establishment of safety committees (with equal representation between management and labor) to serve health and safety-related functions. The elected representatives should have a legally recognized role that goes beyond consultation in activities such as the development of the comprehensive process hazard analysis, management of change, incident investigation, audits, and identification and effective control of hazards. The representatives should also have the authority to stop work that is perceived to be unsafe or that presents a serious hazard until the regulator intervenes to resolve the safety concern. Work force participation practices should be documented by the company to the regulator; and

f. Requires reporting of information to the public to the greatest extent feasible such as a summary of the comprehensive process hazard analysis which includes a list of safeguards implemented and standards utilized to reduce risk, and process safety indicators that demonstrate the effectiveness of the safeguards and management systems.

Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.

2010-08-I-WA-6

Establish a well-funded, well-staffed, technically qualified regulator with a compensation system to
ensure the Washington Department of Labor and Industries regulator has the ability to attract and retain a sufficient number of employees with the necessary skills and experience to ensure regulator technical qualifications. Periodically conduct a market analysis and benchmarking review to ensure the
compensation system remains competitive with Washington petroleum refineries.

Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.

2010-08-I-WA-7

Work with the regulator, the petroleum refining industry, labor, and other relevant stakeholders in the
state of Washington to develop and implement a system that collects, tracks, and analyzes process safety leading and lagging indicators from operators and contractors to promote continuous process safety improvements. At a minimum, this program shall:

a. Require the use of leading and lagging process safety indicators to actively monitor the effectiveness of process safety management systems and safeguards for major accident prevention. Include leading
and lagging indicators that are measureable, actionable, and standardized. Include indicators that measure safety culture, such as incident reporting and action item implementation culture. Require that the reported data be used for continuous process safety improvement and accident prevention;

b. Analyze data to identify trends and poor performer s and publish annual reports with the data at
facility and corporate levels;

d. Use process safety indicators (1) to drive continuous improvement for major accident prevention
by using the data to identify industry and facility safety trends and deficiencies and (2) to
determine appropriate allocation of regulator resources and inspections; and

e. Be periodically updated to incorporate new learning from world-wide industry improvements in order to drive continuous major accident process safety improvements in Washington.

Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.

Implement a process safety culture continuous improvement program at the Tesoro Anacortes Refinery
including a written procedure for periodic process safety culture surveys across the work force. The
process safety culture program shall be overseen by a tripartite committee of Tesoro management, USW
representatives, Washington State Department of Labor and Industries – Division of Occupational Safety
and Health, and the U.S. Environmental Protection Agency. This oversight committee shall:

a. Select an expert third party that will administer a periodic process safety culture survey;

b. Review and comment on the third party expert report developed from the survey;

c. Oversee the development and effective implementation of action items to address identified process safety culture issues; and

The process safety program shall include a focus on items that measure, at a minimum, willingness to
report incidents, normalization of hazardous conditions, burden of proof of safety in plant process safety programs and practices, and management involvement and commitment to process safety. The periodic process safety culture report shall be made available to the plant workforce. The minimum frequency of process safety culture surveys shall be at least once every three years.

Once recommendation 2010-08-I-WA-R12 is in effect, develop and implement a plan to meet therequirements established through the acceptable completion of recommendation 2010-08-I-WA-R10. Document the implementation of the plan and the corrective actions taken.

Revise and improve the Process Hazard Analysis (PHA), the Integrity Operating Window (IOW), and the
damage mechanism hazard review (DMHR) programs and cross-linking among these three programs such that all identified hazards are effectively managed in each program. For all Tesoro refineries require:

a. the IOW to review damage mechanism hazards from the most recent PHA and safeguards identified to control these hazards;

b. the IOW review or revalidation to be conducted at least every five years;

c. the IOW to analyze and incorporate applicable industry best practice, the hierarchy of controls, and inherently safer design to the greatest extent reasonably practicable;

d. the DMHR report to be developed by the DMHR team and not just the “corrosion expert;”

e.the DMHR team to review the operating data to verify an accurate understanding of how the data was obtained, what it represents, and that it appropriately addresses both routine and nonroutine operations;

f. the DMHR and/or IOW review to identify and review gaps between current industry best practices and existing Tesoro practices with regard to material selection and process controls and make recommendations that reduce risks from damage mechanism hazards;

g. the DMHR and IOW review to review applicable Tesoro and industry-wide damage mechanism incidents as part of the respective DMHR or IOW review;

h. the DMHR to review relevant MOCs to fully evaluate the impact of the MOC on damage mechanism hazards;

i. the identification of minimum qualifications for the “corrosion expert” and ensure that the DMHR team has the necessary skills to meet these requirements;

j. for sites that have a corrosion/materials engineer, the corrosion/materials engineer shall be a required participant in the DMHR;

k. the PHA to review the most recent DMHR and IOW reviews in order to contain a complete record of all identified damage mechanism hazards, evaluate existing safeguards, and propose new safeguards to control the identified hazards;

l. the PHA to review the consequence of damage mechanism hazards identified in the risk-based inspection (RBI) program and IOW reviews to ensure effective safeguards are present to control the damage mechanism hazard; and

m. the PHA to use the hierarchy of controls and implement opportunities for inherently safer design
to the greatest extent reasonably practicable.

Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.

Perform a verification audit at all Washington petroleum refineries to ensure:

a. Prevention of HTHA equipment failure and safe operation of the equipment. Audit HTHA prevention and process condition monitoring techniques used at all Washington petroleum refineries. Verify that all affected equipment in use meets the requirements contained in Recommendation 2010-08-I-WA-R10;

b. For nonroutine work, a written hazard evaluation is performed by a multidisciplinary team and, where feasible, conducted during the job planning process prior to the day of the job execution. Verify that each facility has an effective written decision-making protocol used to determine when it is necessary to shut a process down to safely perform work or conduct repairs. Ensure the program reflects the guidance in the CCPS Risk Based Process Safety book related to hazardous nonroutine work; and

c. Effective programs are in place to control of the number of essential personnel present during all
hazardous nonroutine work.

Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.

2010-08-I-WA-9

Effectively participate in the Tesoro Anacortes Refinery process safety culture survey oversight
committee as recommended under recommendation 2010-08-I-WA-R15. Incorporate the expertise of process safety culture experts in the development and interpretation of the safety culture surveys. Ensure
the effective participation of the workforce and their representatives in the development of the surveys and the implementation of corrective actions.

Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.

Closed - No Longer Applicable (C - NLA) - Due to subsequent events, the recommendation action no longer applies (e.g., the facility was destroyed or the company went out of business).

2005-3-I-NJ-2

Implement an effective Process Safety Management program, in accordance with OSHA 1910.119. Include written operating procedures and checklists that are understood by the workers responsible for using them. Train workers on the procedures and periodically confirm that they are being properly followed.

Immediately inform existing acetylene generator users that the check valve did not prevent acetylene gas backflow in this incident. Recommend interim actions be taken to ensure that Rexarc check valves in service on acetylene production equipment will operate reliably.

Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.

Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.

Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.

2011-3-I-WV-4

Conduct a process hazard analysis as defined in NFPA 484-2012, Section 12.2.5, and submit a copy to the local fire department or the enforcing authority for the fire code.

Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.

Issue a standard designed to prevent combustible dust fires and explosions in general industry. Base the standard on current National Fire Protection Association (NFPA) dust explosion standards (including NFPA 654 and NFPA 484), and include at least

Open - Unacceptable Response/No Response Received (O - UR) - Recipient responds by expressing disagreement with the need outlined in the recommendation. The Board believes, however, that there is enough supporting evidence to ask the recipient to reconsider.

Open - Unacceptable Response/No Response Received (O - UR) - Recipient responds by expressing disagreement with the need outlined in the recommendation. The Board believes, however, that there is enough supporting evidence to ask the recipient to reconsider.

Take immediate action to reduce the risk of a catastrophic failure of Tanks 202, 205, and 209 at the Allied Terminals Hill Street facility including but not limited to significantly reducing the maximum liquid levels ("safe fill height") based on sound engineering principles. Report the actions taken to the City of Chesapeake.

Select and retain a qualified, independent tank engineering firm to evaluate Tanks 202, 205, and 209 and determine their fitness for continued service. The evaluation should be based on recognized and generally accepted good engineering practices, such as API 653 - Tank Inspection, Repair Alteration, and Reconstruction and API 579 - Fitness for Service.

Within 30 days, provide the report prepared by the independent tank engineering firm to the City of Chesapeake, together with a comprehensive action plan and schedule to address any identified deficiencies.

Hire a qualified independent reviewer to verify that maximum liquid levels for all tanks at Allied’s Norfolk and Chesapeake terminals meet the requirements of American Petroleum Institute Standard 653, Tank Inspection, Repair, Alteration, and Reconstruction. At a minimum, the review should verify that all requirements for welding, inspection of welds, and In-Service and Out-of-Service tank inspections are met. Make the complete review report for both terminals available to the Cities of Norfolk, Chesapeake, and Portsmouth, Virginia, as well as the Virginia Department of Environmental Quality.

Develop and implement worker safety procedures for initial filling of tanks following major modification or change-in-service. At a minimum, require the exclusion of all personnel from secondary containment during the initial filling.

Require state regulation of 100,000-gallon and larger fertilizer storage tanks (which presently are located solely along and in the area of the Elizabeth River) or authorize local jurisdictions to regulate these tanks. The regulations should: 1) Address design, construction, maintenance, and inspection of 100,000-gallon and larger liquid fertilizer storage tanks, and 2) Incorporate generally recognized and accepted good engineering practice.

Recommend to your membership companies that prepare MSDSs to update the MSDSs to: -Identify and include a warning for materials that are static accumulators and that may form ignitable vapor-air mixtures in storage tanks. -Include a statement that bonding and grounding may be insufficient to eliminate the hazard from static-accumulating flammable liquids, and provide examples of additional precautions and references to the relevant consensus guidance (e.g., NFPA 77, Recommended Practice on Static Electricity (2007), and API Recommended Practice 2003, Protection Against Ignitions Arising Out of Static, Lightning, and Stray Currents (2008)). -Include conductivity testing data for the materials that are static accumulators and that may form ignitable vapor-air mixtures in storage tanks.

Revise ANSI Z400.1 to advise chemical manufacturers and importers that prepare MSDSs to: -Identify and include a warning for materials that are static-accumulators and that may form ignitable vapor-air mixtures in storage tanks; -Advise users that bonding and grounding may be insufficient to eliminate the hazard from static-accumulating flammable liquids, and provide examples of additional precautions and references to the relevant consensus guidance (e.g., NFPA 77, Recommended Practice on Static Electricity (2007), and API Recommended Practice 2003, Protection Against Ignitions Arising Out of Static, Lightning, and Stray Currents (2008)); and -Provide conductivity testing data for materials that are static accumulators and that may form ignitable vapor-air mixtures in storage tanks.

Recommend to your membership companies that prepare MSDSs to update the MSDSs to: -Identify and include a warning for materials that are static accumulators and that may form ignitable vapor-air mixtures in storage tanks. -Include a statement that bonding and grounding may be insufficient to eliminate the hazard from static-accumulating flammable liquids, and provide examples of additional precautions and references to the relevant consensus guidance (e.g., NFPA 77, Recommended Practice on Static Electricity (2007), and API Recommended Practice 2003, Protection Against Ignitions Arising Out of Static, Lightning, and Stray Currents (2008)). -Include conductivity testing data for the materials that are static accumulators and that may form ignitable vapor-air mixtures in storage tanks.

Recommend to your membership companies that prepare MSDSs to update the MSDSs to:
-Identify and include a warning for materials that are static accumulators and that may form ignitable vapor-air mixtures in storage tanks.
-Include a statement that bonding and grounding may be insufficient to eliminate the hazard from static-accumulating flammable liquids, and provide examples of additional precautions and references to the relevant consensus guidance (e.g., NFPA 77, Recommended Practice on Static Electricity (2007), and API Recommended Practice 2003, Protection Against Ignitions Arising Out of Static, Lightning, and Stray Currents (2008)).
-Include conductivity testing data for the materials that are static accumulators and that may form ignitable vapor-air mixtures in storage tanks.

Recommend to your membership companies that prepare MSDSs to update the MSDSs to: -Identify and include a warning for materials that are static accumulators and that may form ignitable vapor-air mixtures in storage tanks. -Include a statement that bonding and grounding may be insufficient to eliminate the hazard from static-accumulating flammable liquids, and provide examples of additional precautions and references to the relevant consensus guidance (e.g., NFPA 77, Recommended Practice on Static Electricity (2007), and API Recommended Practice 2003, Protection Against Ignitions Arising Out of Static, Lightning, and Stray Currents (2008)). -Include conductivity testing data for the materials that are static accumulators and that may form ignitable vapor-air mixtures in storage tanks.

Recommend to your membership companies that prepare MSDSs to update the MSDSs to: -Identify and include a warning for materials that are static accumulators and that may form ignitable vapor-air mixtures in storage tanks. -Include a statement that bonding and grounding may be insufficient to eliminate the hazard from static-accumulating flammable liquids, and provide examples of additional precautions and references to the relevant consensus guidance (e.g., NFPA 77, Recommended Practice on Static Electricity (2007), and API Recommended Practice 2003, Protection Against Ignitions Arising Out of Static, Lightning, and Stray Currents (2008)). -Include conductivity testing data for the materials that are static accumulators and that may form ignitable vapor-air mixtures in storage tanks.

Revise the "Guidance for Hazard Determination for compliance with the OSHA Hazard Communication Standard" to advise chemical manufacturers and importers that prepare MSDSs to: -Evaluate flammable liquids to determine their potential to accumulate static electricity and form ignitable vapor-air mixtures in storage tanks. -Test the conductivity of the flammable liquid and include the testing results in the MSDS.

Open - Acceptable Response or Alternate Response (O - ARAR) - Response from recipient indicates a planned action that would satisfy the objective of the recommendation when implemented.

2007-6-I-KS-2

Prior to the next revision, communicate to the Sub-Committee on the Globally Harmonized System of Classification and Labeling of Chemicals (SCEGHS) the need to amend the GHS to advise chemical manufacturers and importers that prepare MSDSs to:
-Identify and include a warning for materials that are static accumulators and that may form ignitable vapor-air mixtures in storage tanks.
-Advise users that bonding and grounding may be insufficient to eliminate the hazard from static-accumulating flammable liquids, and provide examples of additional precautions and references to the relevant consensus guidance (e.g., NFPA 77, Recommended Practice on Static Electricity (2007), and API Recommended Practice 2003, Protection Against Ignitions Arising Out of Static, Lightning, and Stray Currents (2008)).
-Provide conductivity testing data for materials that are static accumulators and that may form ignitable vapor-air mixtures in storage tanks.

Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.

Recommend to your membership companies that prepare MSDSs to update the MSDSs to: -Identify and include a warning for materials that are static accumulators and that may form ignitable vapor-air mixtures in storage tanks. -Include a statement that bonding and grounding may be insufficient to eliminate the hazard from static-accumulating flammable liquids, and provide examples of additional precautions and references to the relevant consensus guidance (e.g., NFPA 77, Recommended Practice on Static Electricity (2007), and API Recommended Practice 2003, Protection Against Ignitions Arising Out of Static, Lightning, and Stray Currents (2008)). -Include conductivity testing data for the materials that are static accumulators and that may form ignitable vapor-air mixtures in storage tanks.

Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.

2008-08-I-WV-4

Evaluate the fenceline air monitor program against federal, state, and local regulations, and Bayer corporate policies, and upgrade and install air monitoring devices as necessary to ensure effective monitoring of potential releases of high-hazard chemicals at the perimeter of the facility.

Commission an independent human factors and ergonomics study of all Institute site PSM/RMP covered process control rooms to evaluate the human-control system interface, operator fatigue, and control system familiarity and training. Develop and implement a plan to resolve all recommendations identified in the study that includes assigned responsibilities, required corrective actions, and completion dates.

Revise the corporate PHA policies and procedures to require:
a. Validation of all PHA assumptions to ensure that risk analysis of each PHA scenario specifically examines the risk(s) of intentional bypassing or other nullifications of safeguards,
b. Addressing all phases of operation and special topics including those cited in chapter 9 of "Guidelines for Hazard Evaluation Procedures" (CCPS, 2008), and
c. Training all PHA facilitators on the revised policies and procedures prior to assigning the facilitator to a PHA team.
Ensure all PHAs are updated to conform to the revised procedures.

In light of the findings of this report and the serious potential hazards to workers and the public from chemicals used and stored at the Bayer Institute site (such as phosgene, MIC, and methomyl), conduct a comprehensive Risk Management Program (RMP) inspection of the complex. Coordinate with the Occupational Safety and Health Administration, as appropriate.

Establish a Hazardous Chemical Release Prevention Program to enhance the prevention of accidental releases of highly hazardous chemicals, and optimize responses in the event of their occurrence. In establishing the program, study and evaluate the possible applicability of the experience of similar programs in the country, such as those summarized in Section 5.3 of this report. As a minimum:

a. Ensure that the new program:
1. Implements an effective system of independent oversight and other services to enhance the prevention of accidental releases of highly hazardous chemicals
2. Facilitates the collaboration of multiple stakeholders in achieving common goals of chemical safety; and,
3. Increases the confidence of the community, the workforce, and the local authorities in the ability of the facility owners to prevent and respond to accidental releases of highly hazardous chemicals.

b. Define the characteristics of chemical facilities that would be covered by the new Program, such as the hazards and potential risks of their chemicals and processes, their quantities, and similar relevant factors;

d. Ensure that the program has the right to evaluate the documents submitted by the covered facilities, and to require modifications, as necessary

e. Ensure that the program has right-of-entry to covered facilities, and access to requisite information to conduct periodic audits of safety systems and investigations of chemical releases;

f. Establish a system of fees assessed on covered facilities sufficient to cover the oversight and related services to be provided to the facilities including necessary technical and administrative personnel; and,

g. Consistent with applicable law, ensure that the program provides reasonable public participation with the program staff in review of facility programs and access to:
1. The materials submitted by covered facilities (e.g., hazard evaluations, safety plans, emergency response plans);
2. The reviews conducted by program staff and the modifications triggered by those reviews;
3. Records of audits and incident investigations conducted by the program;
4. Performance indicator reports and data submitted by the facilities, and;
5. Other relevant information concerning the hazards and the control methods overseen by the program.

h. Ensure that the program will require a periodic review of the designated agency activities and issue a periodic public report of its activities and recommended action items

Work with the Kanawha and Putnam counties Emergency Response Directors to prepare and issue a revision to the Kanawha Putnam County Emergency Response Plan and Annexes to address facility emergency response and Incident Command when such functions are provided by the facility owner.

In light of the findings of this report and the serious potential hazards to workers and the public from chemicals used and stored at the Bayer Institute site (such as phosgene, MIC, and methomyl), conduct a comprehensive Process Safety Management (PSM) inspection of the complex. Coordinate with the Environmental Protection Agency, as appropriate.

Revise the Chemical National Emphasis Program and the targeting criteria to:
a. Expand the coverage to all OSHA regions,
b. Include in the targeting criteria from which potential inspections are selected all establishments that have submitted certifications of completions of actions in response to previous PSM citations;
c. Require NEP inspections to examine the status of compliance of all previously cited PSM program items for which the company has submitted certifications of completion to OSHA.

Work with the Director of the Kanawha-Charleston Health Department to ensure the successful planning, fee collection, and implementation of the Hazardous Chemical Release Prevention Program as described in Recommendation 2008-08-WV-R6, above, including the provision of services to all eligible facilities in the State.

Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.

Work with the Director of the Kanawha-Charleston Health Department to ensure the successful planning, fee collection, and implementation of the Hazardous Chemical Release Prevention Program as described in Recommendation 2008-08-WV-R6, above, including the provision of services to all eligible facilities in the State.

Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.

Revise the Fire Department Evaluation Administrative Section Matrix addressing the periodic inspection of local fire departments to include a requirement for inspectors to examine and identify the status of National Incident Management System fire department personnel training.

Conduct periodic audits of work authorization, line and equipment opening, deadleg management programs, and decommissioning and demolition activities at your steelmaking facilities. Share findings with the workforce.

Closed - Unacceptable Action/No Response Received (C - UA/NRR) - Recipient responds by expressing disagreement with the need outlined in the recommendation and the Board concludes that further correspondence on, or discussion of, the matter would not change the recipient?s position.

2001-02-I-IN-8

Revise the Material Safety Data Sheet (MSDS) for COG condensate to highlight the potential flammability hazard. Ensure that management at your steelmaking facilities trains employees and informs contractors with regard to the potential
presence of flammable liquids when working with or opening COG condensate piping and equipment.

Closed - Reconsidered/Superseded (C - R/S) - Recipient rejects the recommendation and also supports the rejection with a rationale with which the Board concurs. This designation may apply when later facts indicate that the concerns expressed in the recommendation were actually addressed prior to the incident, or when a recommendation is superseded by a new, more appropriate recommendation.

Implement a work authorization program that requires higher levels of management review, approval, and oversight for jobs that present higher levels of risk, such as opening lines potentially containing flammable liquids where there is no low point drain.

Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.

2001-02-I-IN-3

Survey the mill for deadlegs and implement a program for resolving the hazards. Develop guidance for plant personnel on the risks of deadlegs and their prevention. Include deadlegs in plant winterization planning.

Closed - Unacceptable Action/No Response Received (C - UA/NRR) - Recipient responds by expressing disagreement with the need outlined in the recommendation and the Board concludes that further correspondence on, or discussion of, the matter would not change the recipient?s position.

2001-02-I-IN-4

Provide drains at low points in piping to allow for the safe draining of potentially flammable material.

Closed - Unacceptable Action/No Response Received (C - UA/NRR) - Recipient responds by expressing disagreement with the need outlined in the recommendation and the Board concludes that further correspondence on, or discussion of, the matter would not change the recipient?s position.

2001-02-I-IN-5

Ensure that Burns Harbor and contractor employees are trained with regard to the potential presence of flammable liquids when working with or opening COG or condensate piping and equipment.

Revise CDM policies and procedures to ensure that appropriate quality control measures are applied so that designs specify appropriate materials and comply with applicable safety standards. Ensure that wastewater treatment plant design engineers are aware of the importance of proper material selection as well as the findings and recommendations of this report.

Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.

2006-3-I-FL-12

Communicate the findings and recommendations of this report to all companies that contracted with CDM for methanol and other flammable liquid systems that were constructed with aboveground plastic pipe. Recommend replacing plastic pipe with an appropriate material in accordance with NFPA 30 and OSHA 1910.106.

Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.

2006-3-I-FL-13

Communicate the findings and recommendations of this report to all companies that contracted with CDM for flammable liquid systems that included a flame arrester. Emphasize the importance of periodic maintenance of the flame arrester to ensure its effective performance.

Adopt city ordinances to require departments to implement policies, practices, and procedures concerning safety and health in the workplace for city employees that are at least as effective as relevant OSHA standards. Emphasize compliance with chemical standards, including hot work procedures (OSHA Welding, Cutting, and Brazing Standard, Sections 1910.251 and 1910.252) and chemical hazard communication (OSHA Hazard Communication Standard 29 CFR 1910.1200). Implement procedures to ensure compliance with these policies, practices and procedures.

Enact legislation requiring state agencies and each political subdivision (i.e. counties and municipalities) of Florida to implement policies, practices, procedures, including chemical hazards covering the workplace health and safety of Florida public employees that are at least as effective as OSHA. Establish and fund a mechanism to ensure compliance with these standards. Consider legislation providing coverage of Florida public employees under an occupational safety and health program in accordance with Section 18(b) of the Occupational Safety and Health Act of 1970, and Code of Federal Regulations 29 CFR 1956.1.

Closed - Unacceptable Action/No Response Received (C - UA/NRR) - Recipient responds by expressing disagreement with the need outlined in the recommendation and the Board concludes that further correspondence on, or discussion of, the matter would not change the recipient?s position.

2006-3-I-FL-2

Develop and fund a workplace safety and health consultation program for Florida public employees similar to the private sector program currently administered by the Florida Safety Consultation Program at the University of South Florida.

Closed - Unacceptable Action/No Response Received (C - UA/NRR) - Recipient responds by expressing disagreement with the need outlined in the recommendation and the Board concludes that further correspondence on, or discussion of, the matter would not change the recipient?s position.

Work with the Water Environment Federation to prepare and distribute a technical bulletin containing information on the safe receipt, storage, use, and dispensing of methanol in wastewater treatment plants. In addition, include information on basic fire and explosion prevention measures when using bulk methanol (e.g., flame arrester maintenance, hot work programs, electrical classification).

Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.

Work with the Methanol Institute to prepare and distribute a technical bulletin containing information on the safe receipt, storage, use, and dispensing of methanol in wastewater treatment plants. In addition, include information on basic fire and explosion prevention measures when using bulk methanol (e.g., flame arrester maintenance, hot work programs, electrical classification).

Revise API RP-2219, Safe Operation of Vacuum Trucks in Petroleum Service, and API Order No. G00004, Guidelines for Commercial Exploration and Production Waste Management Facilities, to discuss the hazards of unloading potentially flammable or flammable liquids onto an open unloading area, such as a concrete pad. Recommend other alternatives for minimizing vapor generation, such as unloading of flammable liquids into a closed piping system.

Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.

2003-06-I-TX-17

Communicate the findings and recommendations of this report
to your membership. Emphasize that basic sediment and water
(BS&W) removed from crude oil and condensate storage tanks
requires special handling, in addition to compliance with Occupational Safety and Health Administration (OSHA) or U.S.
Department of Transportation (DOT) regulations, if it contains
sufficient hydrocarbons (either residual or mixed in during the
removal process) to be classified a flammable liquid as defined by each regulation.

Develop a written Waste Acceptance Plan as recommended by API Order No. G00004, Guidelines for Commercial Exploration and Production Waste Management Facilities.
Require the shipper or carrier to properly classify the flammability hazard of exploration and production (E&P) waste liquids.
Require the hauler to provide information that identifies the
flammability hazard of the material before accepting the
load, such as a material safety data sheet (MSDS).

Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.

2003-06-I-TX-9

Develop and implement written procedures and provide training to employees on the safe handling of all waste liquids delivered to the facility in accordance with API Order No. G00004, Guidelines for Commercial Exploration and Production Waste Management Facilities; and API RP-2219, Safe Operation of Vacuum Trucks in Petroleum Service.
Include requirements for proper grounding of trucks and
eliminating other sources of ignition (e.g., facility electrical
equipment and smoking in unloading areas).
Ensure that the material is presented in languages or formats
that are clearly understood by all affected personnel.

Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.

2003-06-I-TX-10

Develop written procedures and provide training to employees on unloading all flammable or potentially flammable E&P waste liquids.
Avoid unloading flammable liquids onto an open work area,
such as the mud disposal and washout pad.
Include alternative unloading method(s), such as using a
closed piping system to minimize vapor generation.
Ensure that the material is presented in languages or formats
that are clearly understood by all affected personnel.

Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.

2003-06-I-TX-11

Develop written emergency procedures and provide training to
employees on response to abnormal or emergency situations,
including uncontrolled flammable vapor releases that can result
in a fire or explosion hazard. Ensure that the material is presented in languages or formats that are clearly understood by all affected personnel.

Provide documentation of the potential flammability hazard of exploration and production (E&P) waste liquids-such as a material safety data sheet (MSDS)- to all employees, contract personnel, and haulers handling waste liquids generated at well sites. Emphasize that mixing condensate with basic sediment and water (BS&W) during the removal process can significantly increase the flammability hazard. The mixture in the transport container should be treated as a flammable liquid absent positive identification to the contrary.

Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.

2003-06-I-TX-2

Review and revise company gauging and waste liquid removal
protocols as necessary to minimize the inadvertent removal and
subsequent disposal of hydrocarbon product when removing
BS&W from product storage tanks.

Issue a Safety and Health Information Bulletin on the potential
flammability hazard associated with bulk transportation of oilfield exploration and production (E&P) waste liquids.
Summarize OSHA requirements for proper hazard classification by the shipper and for the use of material safety data sheets (MSDS).
Summarize U.S. Department of Transportation (DOT) requirements for proper hazard classification and manifesting of flammable liquids, approved container design, and periodic testing.
Discuss safe handling to minimize the generation of flammable vapor and to control ignition sources from vehicle-mounted equipment and facility equipment.
Discuss the need for the employer to provide all worker safety
information in languages or formats that are clearly understood by all affected personnel.
Summarize the requirements for proper labeling of storage tanks to clearly identify the hazard of the contents to all employees and contractors working at the well site.

Ensure that the written procedures for hazard identification
require that all customers requesting loading and transportation
of exploration and production (E&P) waste liquids provide
written notification, such as a material safety data sheet (MSDS),
listing the potential flammability hazard.

Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.

2003-06-I-TX-4

Ensure that the written procedures for safe operation of vacuum
trucks incorporate applicable good practices, including techniques to minimize the possibility of exposing the diesel engine to flammable vapor, as provided in API RP-2219, Guidelines for Commercial Exploration and Production Waste Management Facilities.

Develop written operating procedures that incorporate best
practices for unloading storage tank waste liquids, such that
drivers accurately measure the quantity of liquid removed from
the storage tank and minimize removal of product, such as
flammable condensate.

Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.

2003-06-I-TX-6

Ensure that written emergency procedures address the safe
response to abnormal diesel engine operation due to a flammable vapor atmosphere. Explain that the normal engine
shutoff method will not function as long as flammable vapor
continues to enter the intake system.

Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.

2003-06-I-TX-7

Conduct and document training for all personnel who handle
waste liquids, using languages or formats that are clearly understood by all affected personnel.
Address the potential flammability hazard associated with
E&P waste liquids, emphasizing how the withdrawal
procedure is likely to increase the flammability of the vacuum
truck contents through unavoidable mixing of product and
basic sediment and water (BS&W).
Describe operating and emergency response to diesel engine overspeed caused by a flammable vapor atmosphere.

Require that all permitted drillers and producers identify and document (e.g., material safety data sheet [MSDS]) the potential flammability hazard of exploration and production (E&P) waste liquids. Provide the information to workers and contractors in languages clearly understood by the recipients.

Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.

2003-06-I-TX-15

Provide information (e.g., safety bulletin) to industry on the
potential flammability hazard associated with basic sediment and water (BS&W) and other E&P waste liquids.
Waste liquids can contain sufficient hydrocarbons to be
classified as flammable liquids.
The waste liquid removal method can result in removing
significant quantities of flammable hydrocarbon product such
that the mixture in the transport container may require
classification as a flammable liquid under Occupational Safety
and Health Administration (OSHA) or U.S. Department of
Transportation (DOT) regulations.

Publish an information document for exploration and production (E&P) industry employers (including producers/shippers/offerors, motor carriers, and disposal facility operators) involved in the transportation of basic sediment and water (BS&W) and other E&P waste liquids on public highways. (2003-06-I-TX-R12):
-Emphasize the importance of, and responsibility for, properly
classifying and identifying flammable waste liquids. -Reference the Occupational Safety and Health Administration
(OSHA) requirements for obtaining material safety data sheets
(MSDS) from the shipper and the required content of DOT
shipping papers. -Include specific reference to this CSB Investigation Report and the American Petroleum Institute (API) recommended practices cited in this report.

In light of the findings concerning the March 23rd incident at BP's
Texas City refinery, revise your Recommended Practice 752, Management of Hazards Associated with Location of Process Plant Buildings or issue a new Recommended Practice to ensure the safe placement of occupied trailers and similar temporary structures away from hazardous areas of process plants. Ensure that the new recommended practice:
- Protects occupants from accident hazards such as heat, blast overpressure, and projectiles;
- Establishes minimum safe distances for trailers and similar temporary
structures away from hazardous areas of process plants;
- Evaluates the siting of trailers under a separate methodology from permanent structures, since trailers are more susceptible to damage, are more readily relocated, and likely do not need to be placed near hazardous areas.

Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.

2005-4-I-TX-4

Revise API Recommended Practice 521, Guide for Pressure Relieving and Depressurizing Systems to ensure that the guidelines:
- Identifies overfilling vessels as a potential hazard for evaluation in selecting and designing pressure relief and disposal systems;
- Addresses the need to adequately size disposal drums for credible worse-case liquid relief scenarios, based on accurate relief valve and disposal collection piping studies;
- Warns against the use of atmospheric blowdown drums and stacks attached to collection piping systems that receive flammable discharges from multiple relief valves and urges the use of appropriate inherently safer alternatives such as a flare system

Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.

2005-4-I-TX-6

Work together to develop two new consensus American National Standards Institute (ANSI) standards. a. In the first standard, create performance indicators for process safety in the refinery and petrochemical industries. Ensure that the standard identifies leading and lagging indicators for nationwide public reporting as well as indicators for use at individual facilities. Include methods for the development and use of the performance indicators. (CSB2005-04-I-TX-R6A) In the development of each standard, ensure that a. the committees are accredited and conform to ANSI principles of openness, balance, due process, and consensus; b. include representation of diverse sectors such as industry, labor, government, public interest and environmental organizations and experts from relevant scientific organizations and disciplines.

Work together to develop two new consensus American National Standards Institute (ANSI) standards. b. In the second standard, develop fatigue prevention guidelines for the refining and petrochemical industries that, at a minimum, limit hours and days of work and address shift work. (CSB2005-04-I-TX-R7a) In the development of each standard, ensure that the committees a. are accredited and conform to ANSI principles of openness, balance, due process, and consensus; b. include representation of diverse sectors such as industry, labor, government, public interest and environmental organizations and experts from relevant scientific organizations and disciplines.

Open - Unacceptable Response/No Response Received (O - UR) - Recipient responds by expressing disagreement with the need outlined in the recommendation. The Board believes, however, that there is enough supporting evidence to ask the recipient to reconsider.

1. Commission an independent panel to assess and report on the effectiveness of BP North America's corporate oversight of safety management systems at its
refineries and its corporate safety culture. Provide the panel with necessary
funding, resources, and authority - including full access to relevant data,
corporate records, and employee interviews - in order to conduct a thorough,
independent, and credible inquiry.
2. Ensure that, at a minimum, the panel report examines and recommends any
needed improvements to:
Corporate safety oversight, including the safe management of refineries
obtained through mergers and acquisitions;
Corporate safety culture, including the degree to which:
- Corporate officials exercise appropriate leadership to promote adherence
to safety management systems;
- Process safety is effectively incorporated into management decisionmaking
at all levels;
- Employees at all levels are empowered to promote improved process
safety;
- Process safety programs receive adequate resources and are appropriately
positioned within organizational structures;
Corporate and site safety management systems, specifically:
- Near-miss reporting and investigation programs;
- Mechanical integrity programs;
- Hazard analysis programs, management-of-change programs, and up-todate
operating procedures for processes with catastrophic potential;
- Siting policies for occupied structures near hazardous operating units.
3. Ensure that the panel has a diverse makeup, including an external chairperson;
employee representatives; and outside safety experts, such as experts in process
safety; experts in corporate culture, organizational behavior, and human factors;
and experts from other high-risk sectors such as aviation, space exploration,
nuclear energy, and the undersea navy.
4. Ensure that the report and recommendations of the independent panel, which
should be completed within 12 months, are made available to the BP workforce
and to the public.

Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.

2005-4-I-TX-11

1. Appoint an additional non-executive member of the Board of Directors with specific professional expertise and experience in refinery operations and process safety. Appoint this person to be a member of the Board Ethics and Environmental Assurance Committee.

Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.

2005-4-I-TX-12

2. Ensure and monitor that senior executives implement an incident reporting program throughout your refinery organization that a. encourages the reporting of incidents without fear of retaliation; b. requires prompt corrective actions based on incident reports and recommendations, and tracks closure of action items at the refinery where the incident occurred and other affected facilities; and c. requires communication of key lessons learned to management and hourly employees as well as to the industry.

Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.

2005-4-I-TX-13

3. Ensure and monitor that senior executives use leading and lagging process safety indicators to measure and strengthen safety performance in your refineries.

Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.

2005-4-I-TX-16

3. Work with the United Steelworkers Union and Local 13-1 to establish a joint program that promotes the reporting, investigation, and analysis of incidents, near-misses, process upsets, and major plant hazards without fear of retaliation. Ensure that the program tracks recommendations to completion and shares lessons learned with the workforce.

Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.

2005-4-I-TX-15

2. Ensure that instrumentation and process equipment necessary for safe operation is properly maintained and tested. At a minimum, a. Establish an equipment database that captures the history of testing, inspections, repair, and successful work order completion. b. Analyze repair trends and adjust maintenance and testing intervals to prevent breakdowns. c. Require repair of malfunctioning process equipment prior to unit startups.

Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.

2005-4-I-TX-17

4. Improve the operator training program. At a minimum, require a. face-to-face training conducted by personnel with process-specific knowledge and experience who can assess trainee competency, and; b. training on recognizing and handling abnormal situations including the use of simulators or similar training tools.

Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.

2005-4-B-TX-1

Revise the maintenance quality control program to require positive material identification testing or another suitable material verification process for all critical service alloy steel piping components removed and reinstalled during maintenance and inform work crews of special material handling precautions.

Issue management of change guidelines that address the safe control of the following: a. major organizational changes including mergers, acquisitions, and reorganizations; b. changes in policies and budgets; c. personnel changes; d. staffing during process startups, shutdowns and other abnormal conditions.

1. Implement a national emphasis program for all oil refineries that focuses on: - The hazards of blowdown drums and stacks that release flammables to the atmosphere instead of to an inherently safer disposal system such as a flare. Particular attention should be paid to blowdown drums attached to collection piping systems servicing multiple relief valves; - The need for adequately sized disposal knockout drums to safely contain discharged flammable liquid based on accurate relief valve and disposal collection piping studies 2. Urge states that administer their own OSHA plan to implement comparable emphasis programs within their respective jurisdictions.

1. Strengthen the planned comprehensive enforcement of the OSHA Process Safety Management (PSM) standard. At a minimum: a. Identify those facilities at greatest risk of a catastrophic accident by using available indicators of process safety performance and information gathered by the EPA under its Risk Management Program (RMP). b. Conduct, or have conducted, comprehensive inspections, such as those under your Program Quality Verification (PQV) program at facilities identified as presenting the greatest risk. c. Establish the capacity to conduct more comprehensive PSM inspections by hiring or developing a sufficient cadre of highly trained and experienced inspectors. d. Expand the PSM training offered to inspectors at the OSHA National Training Institute.

Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.

2005-4-I-TX-9

2. Amend the OSHA PSM standard to require that a management of change (MOC) review be conducted for organizational changes that may impact process safety including: a. major organizational changes such as mergers, acquisitions, or reorganizations; b. personnel changes, including changes in staffing levels or staff experience; and c. policy changes such as budget cutting.

Open - Unacceptable Response/No Response Received (O - UR) - Recipient responds by expressing disagreement with the need outlined in the recommendation. The Board believes, however, that there is enough supporting evidence to ask the recipient to reconsider.

Work together to develop two new consensus American National Standards Institute (ANSI) standards. a. In the first standard, create performance indicators for process safety in the refinery and petrochemical industries. Ensure that the standard identifies leading and lagging indicators for nationwide public reporting as well as indicators for use at individual facilities. Include methods for the development and use of the performance indicators.(CSB2005-04-I-TX-R6b) In the development of each standard, ensure that the committees a. are accredited and conform to ANSI principles of openness, balance, due process, and consensus; b. include representation of diverse sectors such as industry, labor, government, public interest and environmental organizations and experts from relevant scientific organizations and disciplines.

Work together to develop two new consensus American National Standards Institute (ANSI) standards.
b. In the second standard, develop fatigue prevention guidelines for the refining and petrochemical industries that, at a minimum, limit hours and days of work and address shift work. (CSB2005-04-I-TX-R7b)
In the development of each standard, ensure that the committees
a. are accredited and conform to ANSI principles of openness, balance, due process, and consensus;
b. include representation of diverse sectors such as industry, labor, government, public interest and environmental organizations and experts from relevant scientific organizations and disciplines.

Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.

Work with BP to establish a joint program that promotes reporting, investigating, and analyzing incidents, near-misses, process upsets, and major plant hazards without fear of retaliation. Ensure that the program tracks recommendations to completion and shares lessons learned with the workforce.

Examine the manufacturing businesses acquired from
BP Amoco Performance Polymers and ensure that a systematic safety review procedure is developed and implemented for identifying and controlling hazards from unintended chemical reactions. Additionally, ensure that reactive hazards are identified and evaluated:
- During product R&D, during conceptual design of a new
process, and during detailed design of a new process.
- Before changes are made to existing equipment or process
chemistry.
- Communicate the results of this review to the workforce.

Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.

2001-03-I-GA-2

Ensure that a program is in place at facilities acquired from
BP Amoco Performance Polymers to systematically review the
hazards associated with new and modified processes and equipment as operating experience accrues. Ensure that facilities correct all identified design, operation, and maintenance deficiencies. Verify that operating experience does not invalidate the design basis for equipment.

Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.

2001-03-I-GA-3

Revise the Material Safety Data Sheet (MSDS) for Amodel to warn of the hazards of accumulating large masses of molten polymer. Communicate the MSDS changes to current and past customers (who may retain inventories of this product).

Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.

2001-03-I-GA-4

Implement a program to conduct periodic management reviews of incidents and near-miss incidents. Look for trends and patterns among incidents. Address root causes and implement and track corrective measures.

Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.

2001-03-I-GA-7

Revise your lockout/tagout program to ensure that equipment is
rendered safe prior to opening for maintenance. At a minimum,
ensure that equipment opening procedures contain a stop work
provision that requires higher levels of management review and
approval when safe opening conditions, such as equipment
depressurization, cannot be verified.

Closed - Unacceptable Action/No Response Received (C - UA/NRR) - Recipient responds by expressing disagreement with the need outlined in the recommendation and the Board concludes that further correspondence on, or discussion of, the matter would not change the recipient?s position.

Revise 527 CMR 14 to specify the maximum interval (such as annually) for local fire departments to conduct inspections of manufacturing facilities holding one or more licenses and permits to store and handle flammable materials.

Develop mandatory written inspection criteria to be used by the local fire departments when performing manufacturing facility inspections. Develop inspection training material and provide training to the local fire departments.

Revise the license and registration forms (FP-2 and FP-5) to require listing each hazardous material type and quantity. Identify the requirement that a separate license and permit are required for each of the eight classes of flammable material when the facility possesses more than the listed threshold quantity specified in 527 CMR 14.03 (2).

Revise the General Laws of Massachusetts addressing flammable materials licensing and registration: - As part of the annual registration renewal, require new and existing product manufacturing registrants to submit written certification to local governments stating that the facility complies with, at a minimum, all state and local fire codes and hazardous chemical regulations. -Require all companies holding a license and current registration to apply for an amended license and re-register the facility before increasing any flammable material quantity above the licensed amount or adding a different regulated chemical. Include a requirement in the approval process to solicit input from affected landowners, similar to the requirement for obtaining the original license and registration.

Amend the General Laws of Massachusetts to require the Office of the State Fire Marshal to audit local governments for compliance with the flammable materials licensing regulation and audit fire departments for compliance with permit issuance and inspection of manufacturing facilities licensed to store and handle flammable liquids and solids. The audits should be conducted at least once every five years.

Revise the International Fire Code: Chapter 20: - Specifically include "printing inks" in the definition of "organic coating." - Define equipment specifically discussed in the standard, such as open and closed kettles. - Require heated tanks and vessels containing flammable and combustible liquids to have equipment to prevent overheating, such as: devices to stop the heating process if the temperature exceeds the safe operating limits; devices to stop the heating process if the flammable vapor control equipment malfunctions (e.g., building ventilation system or heated tank vent); and a heating medium that is unable to heat the tank above safe operating temperatures. Chapters 20, 27, and 34: -Define "open", "closed", and "sealed and vented" process tanks. -Define "non-listed" process tanks. -Prohibit heating flammable and combustible liquids above their flashpoints in tanks inside buildings unless the tanks are sealed and vented to the building exterior.

Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.

Revise Flammable and Combustible Liquids Code (NFPA 30): - Prohibit heating flammable and combustible liquids above their flashpoints in tanks inside buildings, unless the tanks are sealed and vented to the building exterior. - Require heated tanks and vessels containing flammable and combustible liquids to have equipment to prevent overheating, such as: devices to stop the heating process if the temperature exceeds the safe operating limits; devices to stop the heating process if the flammable vapor control equipment malfunctions (e.g., building ventilation system or heated tank vent); and a heating medium that is unable to heat the tank above safe operating temperatures.

Revise The Standard for the Manufacture of Organic Coatings (NFPA 35): -Define equipment specifically discussed in the standard, such as kettles and thin-down tanks. -Define the terms "open, "closed", and "sealed" and "vented." -Prohibit heating flammable and combustible liquids above their flashpoints in tanks inside buildings unless the tanks are sealed and vented to the building exterior. -Require heated tanks and vessels containing flammable and combustible liquids to have equipment to prevent overheating, such as: Devices to stop the heating process if the temperature exceeds the safe operating limits; Devices to stop the heating process if the flammable vapor control equipment malfunctions (e.g., building ventilation system or heated tank vent); and a heating medium that is unable to heat the tank above safe operating temperatures.

Pending revision of the Massachusetts Fire Safety Code (527 CMR), revise the town bylaws addressing 527 CMR 14 requirements applicable to facility licensing and annual registration to: -Require new and current product manufacturing registrants to certify in writing that the facility complies with, at a minimum, all state and local fire codes and hazardous chemical regulations as part of the annual registration renewal. -Require companies holding a license and current registration for any of the eight classes of flammable materials specified in 527 CMR 14.03 (2) to re-register the facility before increasing any chemical quantity above the registered amount or adding a different regulated chemical at the facility. Include a requirement in the approval process to solicit input from affected landowners, similar to the requirement for obtaining the original license and registration. -Revise the license and registration forms to require listing each hazardous material type and quantity, and require a separate license and permit for each of the eight classes of flammable materials specified in 527 CMR 14.03 (2) . -Require the fire department to annually inspect licensed manufacturing facilities for compliance with the fire code.

Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.

Open - Acceptable Response or Alternate Response (O - ARAR) - Response from recipient indicates a planned action that would satisfy the objective of the recommendation when implemented.

2011-5-I-KY-3

Implement a mechanical integrity program for the electric arc furnace and cover, including preventive maintenance based on periodic inspections, and timely replacement of the furnace cover. At a minimum, the program should include factors such as leak detection and repair and refractory lining wear.

a. Require users to identify carbon steel piping circuits susceptible to sulfidation corrosion that may contain low-silicon components. These circuits have the potential to contain carbon steel components that were not manufactured to the American Society for Testing and Materials (ASTM) A106 specification and may contain less than 0.10 weight percent silicon content.

b. For piping circuits identified to meet the specifications detailed in 2012-03-I-CA-R26(a), require users to either (1) enact a program to inspect every component within the piping circuit once, known as 100 percent component inspection (per the requirements established pursuant to recommendation 2012-03-I-CA-R28(c)), or (2) replace the identified at-risk carbon steel piping with a steel alloy that is more resistant to sulfidation corrosion.

c. If low-silicon components or components with accelerated corrosion are identified in a carbon steel piping circuit meeting the specifications detailed in 2012-03-I-CA-R26(a), require designation of these components as permanent Condition Monitoring Locations (CMLs) until the piping components are replaced.

Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.

Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.

b. Specify that sulfidation corrosion rates in carbon steel piping can be significantly faster in some individual piping components than in others;

c. Establish a new section that details inspection requirements to identify low-silicon piping components in carbon steel circuits susceptible to sulfidation corrosion. This section shall require users to identify carbon steel piping circuits at risk to contain low-silicon components by following the requirements detailed in API RP 939-C: Guidelines for Avoiding Sulfidation (Sulfidic) Corrosion Failures in Oil Refineries (pursuant to 2012-03-I-CA-R26(a)) and API RP 578: Material Verification Program for New and Existing Alloy Piping Systems (pursuant to 2012-03-I-CA-R29). At a minimum, require users to either:

i. Inspect every component within all carbon steel piping circuits susceptible to sulfidation corrosion that may contain low-silicon components once. The purpose of this practice is to identify any low-silicon components that are corroding at accelerated rates. Inspection may be performed through ultrasonic thickness measurements to establish corrosion rates for each component, destructive laboratory analysis, or other methods. Following the inspection, require users to follow the low-silicon corrosion rate monitoring requirements established in 2012-03-I-CA-R26(c); or

ii. Replace the identified at-risk carbon steel piping with a steel alloy that is more resistant to sulfidation corrosion.

Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.

2012-03-I-CA-29

Revise API RP 578: Material Verification Program for New and Existing Alloy Piping Systems, to require users to establish and implement a program to identify carbon steel piping circuits that are susceptible to sulfidation corrosionand may contain low-silicon components. These circuits have the potential to contain carbon steel components that were not manufactured to the American Society for Testing and Materials (ASTM) A106 specification and may contain less than 0.10 weight percent silicon content. Refer the reader to the 100 percent component inspection or pipe replacement requirements detailed in API RP 939-C: Guidelines for Avoiding Sulfidation (Sulfidic) Corrosion Failures in Oil Refineries (pursuant to recommendation 2012-03-I-CA-26(b)) and API 570: Piping Inspection Code: In-service Inspection, Rating, Repair, and Alteration of Piping Systems (pursuant to 2012-03-I-CA-28(c)) for carbon steel piping circuits susceptible to sulfidation corrosion that may contain low-silicon components.

Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.

Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.

2012-03-I-CA-31

Revise API RP 2001: Fire Protection in Refineries to require users to develop a process fluid leak response protocol specific to their own facility that must be followed when a process fluid leak is discovered. Recommend users to incorporate the following actions into their leak response protocol:

a. Establish an Incident Command structure upon identification of a process fluid leak;

c. Establish a hot zone that identifies the area of risk of exposure or injuries due to flame contact, radiant heat, or contact to hazardous materials, taking into consideration the worst-case leak scenario;

e. Isolate the leaking piping or vessel, or if isolation is not possible, shutdown of the unit when the leaking process fluid poses immediate danger to safety, health, or the environment—such as piping fluid that is toxic or near the autoignition temperature.

Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.

Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.

Revise the Industrial Safety Ordinance (ISO) to require that Process Hazard Analyses include documentation of the recognized methodologies, rationale and conclusions used to claim that safeguards intended to control hazards will be effective. This process shall use established qualitative, quantitative, and/or semi-quantitative methods such as Layers of Protection Analysis (LOPA).

Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.

2012-03-I-CA-7

Revise the Industrial Safety Ordinance (ISO) to require the documented use of inherently safer systems analysis and the hierarchy of controls to the greatest extent feasible in establishing safeguards for identified process hazards. The goal shall be to drive the risk of major accidents to As Low As Reasonably Practicable (ALARP). Include requirements for inherently safer systems analysis to be automatically triggered for all Management of Change and Process Hazard Analysis reviews, prior to the construction of new processes, process unit rebuilds, significant process repairs, and in the development of corrective actions from incident investigation recommendations.

Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.

2012-03-I-CA-8

Monitor and confirm the effective implementation of the damage mechanism hazard review program (2012-03-I-CA-R1 and 2012-03-I-CA-R2), so that all necessary mechanical integrity work at the Chevron Richmond Refinery is identified and recommendations are completed in a timely way.

Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.

2012-03-I-CA-16

Participate in the joint regulatory program described in recommendation 2012-03-I-CA-R11. This participation shall include contributing relevant data to the repository of investigation and inspection data created by the California Department of Industrial Relations and jointly coordinating activities.

Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.

2012-03-I-CA-25

Implement a compensation system to ensure the regulator has the ability to attract and retain a sufficient number of employees with the necessary skills and experience to ensure regulator technical competency at all levels of process safety regulatory oversight and policy development in Contra Cost County, California. A market analysis and benchmarking review should be periodically conducted to ensure the compensation system remains competitive with California petroleum refineries.

Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.

2012-03-I-CA-36

Revise the Industrial Safety Ordinance (ISO) regulations for petroleum refineries to require a process safety culture continuous improvement program including a written procedure for periodic process safety culture surveys across the work force. Require an oversight committee comprised of the regulator, the company, the company’s workforce and their representatives, and community representatives. This oversight committee shall:

a. Select an expert third party that will administer a periodic process safety culture survey;

b. Review and comment on the third party expert report developed from the survey;

c. Oversee the development and effective implementation of action items to effectively address identified process safety culture issues; and

Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.

Participate in the joint regulatory program described in recommendation 2012-03-I-CA-R11. This participation shall include contributing relevant data to the repository of investigation and inspection data created by the California Department of Industrial Relations and jointly coordinating activities.

Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.

Participate in the joint regulatory program described in recommendation 2012-03-I-CA-R11. This participation shall include contributing relevant data to the repository of investigation and inspection data created by the California Department of Industrial Relations and jointly coordinating activities.

Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.

At all Chevron U.S. refineries, engage a diverse team of qualified personnel to perform a documented damage mechanism hazard review. This review shall be an integral part of the Process Hazard Analysis cycle and shall be conducted on all PSM-covered process piping circuits and process equipment. The damage mechanism hazard review shall identify potential process damage mechanisms and consequences of failure, and shall ensure safeguards are in place to control hazards presented by those damage mechanisms. Analyze and incorporate into this review applicable industry best practices, Chevron Energy Technology Company findings and recommendations, and inherently safer systems to the greatest extent feasible.

Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.

2012-03-I-CA-2

At all California Chevron U.S. refineries, report leading and lagging process safety indicators, such as the action item completion status of recommendations from damage mechanism hazard reviews, to the federal, state, and local regulatory agencies that have chemical release prevention authority.

Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.

2012-03-I-CA-33

Develop a method to assign accountability at Chevron to determine whether any whether any new Energy Technology Company (ETC) recommended program or industry best practice, such as API guidance must be followed to ensure process safety or employee personal safety. This method shall include monitoring of these practices and guidance at a refining system level and at the refinery level. Develop a tracking system to monitor the progress of implementing these selected practices and guidance to completion.

Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.

2012-03-I-CA-34

Develop an auditable process to be available for all recommended turnaround work items necessary to address mechanical integrity deficiencies or inspection recommendations that are denied or deferred. This process shall provide the submitter of the denied or deferred recommendation with the option to seek further review by his or her manager, who can further elevate and discuss the recommendation with higher level management, such as the Area Business Unit Manager. Maintain an auditable log of each of these potential turnaround work items, including the ultimate determination of approval, deferral, or rejection, justification determination, and the person or team responsible for that decision.

Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.

2012-03-I-CA-35

Develop an approval process that includes a technical review that must be implemented prior to resetting the minimum alert thickness to a lower value in the inspection database.

Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.

Jointly plan and conduct inspections with Cal/OSHA, California EPA and other state and local regulatory agencies with chemical accident prevention responsibilities to monitor the effective implementation of the damage mechanism hazard review and disclosure requirements under 2012-03-I-CA-R9 and R10 above.

Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.

2012-03-I-CA-19

Participate in the joint regulatory program described in recommendation 2012-03-I-CA-R11. This participation shall include contributing relevant data to the repository of investigation and inspection data created by the California Department of Industrial Relations and jointly coordinating activities.

Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.

Revise the California Code of Regulations, Title 8, Section 5189, Process Safety Management of Acutely Hazardous Materials, to require improvements to mechanical integrity and process hazard analysis programs for all California oil refineries. These improvements shall include engaging a diverse team of qualified personnel to perform a documented damage mechanism hazard review. This review shall be an integral part of the Process Hazard Analysis cycle and shall be conducted on all PSM-covered process piping circuits and process equipment. The damage mechanism hazard review shall identify potential process damage mechanisms and consequences of failure, and shall ensure safeguards are in place to control hazards presented by those damage mechanisms. Require the analysis and incorporation of applicable industry best practices and inherently safety systems to the greatest extent feasible into this review.

Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.

2012-03-I-CA-10

For all California oil refineries, identify and require the reporting of leading and lagging process safety indicators, such as the action item completion status of recommendations from damage mechanism hazard reviews, to state and local regulatory agencies that have chemical release prevention authority. These indicators shall be used to ensure that requirements described in 2012-03-I-CA-R9 are effective at improving mechanical integrity and process hazard analysis performance at all California oil refineries and preventing major chemical incidents.

Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.

2012-03-I-CA-11

Establish a multi-agency process safety regulatory program for all California oil refineries to improve the public accountability, transparency, and performance of chemical accident prevention and mechanical integrity programs. This program shall:

Establish a system to report to the regulator the recognized methodologies, findings, conclusions and corrective actions related to refinery mechanical integrity inspection and repair work arising from Process Hazard Analyses, California oil refinery turnarounds and maintenance-related shutdowns;

Require reporting of information such as damage mechanism hazard reviews, notice of upcoming maintenance-related shutdowns, records related to proposed and completed mechanical integrity work lists, and the technical rationale for any delay in work proposed but not yet completed;

Establish procedures for greater workforce and public participation including the public reporting of information; and

Provide mechanisms for federal, state and local agency operational coordination, sharing of data (including safety indicator data), and joint accident prevention activities. The California Department of Industrial Relations will be designated as the lead state agency for establishing a repository of joint investigative and inspection data, coordinating the sharing of data and joint accident prevention activities.

Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.

2012-03-I-CA-12

Require that Process Hazard Analyses required under California Code of Regulations, Title 8, Section 5189 Section (e) include documentation of the recognized methodologies, rationale and conclusions used to claim that safeguards intended to control hazards will be effective. This process shall use established qualitative, quantitative, and/or semi-quantitative methods such as Layers of Protection Analysis (LOPA).

Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.

2012-03-I-CA-13

Require the documented use of inherently safer systems analysis and the hierarchy of controls to the greatest extent feasible in establishing safeguards for identified process hazards. The goal shall be to drive the risk of major accidents to As Low As Reasonably Practicable (ALARP). Include requirements for inherently safer systems analysis to be automatically triggered for all Management of Change and Process Hazard Analysis reviews, prior to the construction of new process, process unit rebuilds, significant process repairs and in the development of corrective actions from incident investigation recommendations.

Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.

2012-03-I-CA-14

Monitor and confirm the effective implementation of the damage mechanism hazard review program (2012-03-I-CA-R9 and 2012-03-I-CA-R10), so that all necessary mechanical integrity work at all California Chevron Refineries is identified and recommendations are completed in a timely way.

Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.

2012-03-I-CA-21

Based on the findings in this report, enhance and restructure California’s process safety management (PSM) regulations for petroleum refineries by including the following goal-setting attributes:

a. Require a comprehensive process hazard analysis (PHA) written by the company that includes:

i. Systematic analysis and documentation of all major hazards and safeguards, using the hierarchy of controls to identify hazards and significantly reduce risks to a goal of as low as reasonably practicable (ALARP) or similar;

ii. Documentation of the recognized methodologies, rationale and conclusions used to claim that inherently safer systems have been implemented to as low as reasonably practicable (ALARP) or similar, and that additional safeguards intended to control remaining hazards will be effective;

iii. Documented damage mechanism hazard review conducted by a diverse team of qualified personnel. This review shall be an integral part of the process hazard analysis (PHA) cycle and shall be conducted on all covered processes, piping circuits and equipment. The damage mechanism hazard review shall identify potentia process damage mechanisms and consequences of failure, and shall ensure effective safeguards are in place to prevent or control hazards presented by those damage mechanisms. Require the analysis and incorporation of applicable industry best practices and inherently safer design to the greatest extent feasible into this review; and

iv. Documented use of inherently safer systems analysis and the hierarchy of controls to the greatest extent feasible in establishing safeguards for identified process hazards. The goal shall be to drive the risk of major accidents to As Low As Reasonably Practicable (ALARP) or similar. Include requirements for inherently safer systems analysis to be automatically triggered for all management of change (MOC) and process hazard analysis (PHA) reviews, as well as prior to the construction of new processes, process unit rebuilds, significant process repairs, and in the development of corrective actions from incident investigation recommendations.

c. Require preventative audits and preventative inspections by the regulator to ensure the effective implementation of the comprehensive process hazard analysis (PHA);

d. Require that all safety codes, standards, employer internal procedures and recognized and generally accepted good engineering practices (RAGAGEP) used in the implementation of the regulations contain adequate minimum requirements;

e. Require mechanisms for the regulator, the refinery, and workers and their representatives to play an equal and essential role in the direction of preventing major incidents. Require an expanded role for workers in management of process safety by establishing the rights and responsibilities of workers and their representatives on health and safety-related matters, and the election of safety representatives and establishment of safety committees (with equal representation between management and labor) to serve health and safety-related functions. The elected representatives should have a legally recognized role that goes beyond consultation in activities such as the development of the comprehensive process hazard analysis, implementation of corrective actions generated from hierarchy of control analyses, management of change, incident investigation, audits, and the identification, prevention, and control of all processhazards. The regulation should provide workers and their representatives with the authority to stop work that is perceived to be unsafe until the employer resolves the matter or the regulator intervenes. Workforce participation practices should be documented by the refinery to the regulator;

f. Require reporting of information to the public to the greatest extent feasible, such as a summary of the comprehensive process hazard analysis (PHA) which should include a list of inherently safer systems implemented; safeguards implemented for remaining hazards; standards utilized to reduce risks to As Low As Reasonably Practicable (ALARP) or similar; and process safety indicators that demonstrate the effectiveness of the safeguards and management systems;

g. Implement an approach or system that determines when new or improved industry standards and practices are needed and initiate programs and other activities, such as an advisory committee or forum, toprompt the timely development and implementation of such standards and practices; and

h. Ensure that a means of sustained funding is established to support an independent, well-funded, well-staffed, technically competent regulator.

Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.

2012-03-I-CA-22

Implement a compensation system to ensure the regulator has the ability to attract and retain a sufficient number of employees with the necessary skills and experience to ensure regulator technical competency at all levels of process safety regulatory oversight and policy development in California. A market analysis and benchmarking review should be periodically conducted to ensure the compensation system remains competitive with California petroleum refineries.

Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.

2012-03-I-CA-23

Work with the regulator, the petroleum refining industry, labor, and other relevant stakeholders in the state of California to develop and implement a systemthat collects, tracks, and analyzes process safety leading and lagging indicators from refineries and contractors to promote continuous safety improvements. At a minimum, this program shall:

a. Require the use of leading and lagging process safety indicators to actively monitor the effectiveness of process safety management systems and safeguards for major accident prevention. Include leading and lagging indicators that are measureable, actionable, and standardized. Require that the reported data be used for continuous process safety improvement and accident prevention;

b. Analyze data to identify trends and poor performers and publish annual reports with the data at facility and corporate levels;

d. Use process safety indicators (1) to drive continuous improvement for major accident prevention by using the data to identify industry and facility safety trends and deficiencies and (2) to determine appropriate allocation of regulator resources and inspections; and

e. Be periodically updated to incorporate new learning from world-wide industry improvements in order to drive continuous major accident safety improvements in California.

Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.

Revise the Industrial Safety Ordinance (ISO) to require that Process Hazard Analyses include documentation of the recognized methodologies, rationale and conclusions used to claim that safeguards intended to control hazards will be effective. This process shall use established qualitative, quantitative, and/or semi-quantitative methods such as Layers of Protection Analysis (LOPA).

Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.

2012-03-I-CA-4

Revise the Industrial Safety Ordinance (ISO) to require the documented use of inherently safer systems analysis and the hierarchy of controls to the greatest extent feasible in establishing safeguards for identified process hazards. The goal shall be to drive the risk of major accidents to As Low As Reasonably Practicable (ALARP). Include requirements for inherently safer systems analysis to be automatically triggered for all Management of Change and Process Hazard Analysis reviews, prior to the construction of new processes, process unit rebuilds, significant process repairs, and in the development of corrective actions from incident investigation recommendations.

Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.

2012-03-I-CA-5

Ensure the effective implementation of the damage mechanism hazard review program (2012-03-I-CA-R1 and 2012-03-I-CA-R2), so that all necessary mechanical integrity work at the Chevron Richmond Refinery is identified and recommendations are completed in a timely way

Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.

2012-03-I-CA-17

Participate in the joint regulatory program described in recommendation 2012-03-I-CA-R11. This participation shall include contributing relevant data to the repository of investigation and inspection data created by the California Department of Industrial Relations and jointly coordinating activities.

Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.

2012-03-I-CA-24

Implement or cause to be implemented a compensation system to ensure the regulator has the ability to attract and retain a sufficient number of employees with the necessary skills and experience to ensure regulator technical competency at all levels of process safety regulatory oversight and policy development in Richmond, California. A market analysis and benchmarking review should be periodically conducted to ensure the compensation system remains competitive with California petroleum refineries.

Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.

2012-03-I-CA-37

Revise the Richmond Industrial Safety Ordinance (RISO) regulations for petroleum refineries to require a process safety culture continuous improvement program including a written procedure for periodic process safety culture surveys across the work force. Require an oversight committee comprised of the regulator, the company, the company’s workforce and their representatives, and community representatives. This oversight committee shall:

a. Select an expert third party that will administer a periodic process safety culture survey;

b. Review and comment on the third party expert report developed from the survey;

c. Oversee the development and effective implementation of action items to effectively address identified process safety culture issues; and

Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.

Within 30 days, develop and initiate actions to ensure adequate water supply to the CITGO HF mitigation system.Actions could include, but are not limited to, increasing onsite storage capacity, installing a permanent backup system, and developing procedures and training for water management in an emergency.

Every 30 days, report actions planned or completed to the Refinery Terminal Fire Company and Local Emergency Planning Committee.Continue the 30-day periodic reporting until all planned actions are fully implemented.

Within 60 days, complete a third-party audit of all (Corpus Christi, TX and Lemont, IL) CITGO HF alkylation unit operations in the United States as recommended by API Recommended Practice 751, Safe Operation of Hydrofluoric Acid Alkylation Units, Third Edition June 2007. The selected lead auditor shall have extensive knowledge of HF hazards, HF alkylation units, and API 751.

Consistent with the employee participation requirements of the Process Safety Management Standard for Highly Hazardous Chemicals (29 CFR 1910.119(c)), share all audit results and actions planned or completed to correct deficiencies in each refinery with all CITGO and contract employees whose work area includes that refinery’s alkylation unit.

Develop a combustible dust safety program using good practice guidelines, such as NFPA 654, Standard for the Prevention of Fire and Dust Explosions from the Manufacturing, Processing, and Handling of Combustible Particulate Solids. At a minimum:
Minimize surfaces where combustible dust could accumulate in the design or modification of the plant.

Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.

2003-09-I-KY-2

Develop a combustible dust safety program using good practice guidelines, such as NFPA 654, Standard for the Prevention of Fire and Dust Explosions from the Manufacturing, Processing, and Handling of Combustible Particulate Solids. At a minimum: Ensure phenolic resin-handling facilities are designed to prevent the spread of fires or explosions involving combustible dust. Options include measures such as the use of firewalls and blast-resistant construction.

Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.

2003-09-I-KY-3

Develop a combustible dust safety program using good practice guidelines, such as NFPA 654, Standard for the Prevention of Fire and Dust Explosions from the Manufacturing, Processing, and Handling of Combustible Particulate Solids. At a minimum:
Prevent the unsafe accumulation and dispersion of combustible dust by frequently cleaning process areas, including locations above production lines.

Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.

2003-09-I-KY-4

Develop a combustible dust safety program using good practice guidelines, such as NFPA 654, Standard for the Prevention of Fire and Dust Explosions from the Manufacturing, Processing, and Handling of Combustible Particulate Solids. At a minimum: Minimize the dispersion of combustible dust by using appropriate dust-cleaning methods and tools.

Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.

2003-09-I-KY-5

Develop a combustible dust safety program using good practice guidelines, such as NFPA 654, Standard for the Prevention of Fire and Dust Explosions from the Manufacturing, Processing, and Handling of Combustible Particulate Solids. At a minimum:
Address the dangers of combustible dust and the prevention of dust explosions in the hazard communication training program.

Incorporate the findings and recommendations of this report in your continuing training of inspectors, plan reviewers, technical advisors, and fire marshal general inspectors who interface with facilities that may handle combustible dusts.

Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.

2003-09-I-KY-18

Identify sites that handle combustible dusts when facilities apply for new or modified construction permits, and use this information to help prioritize establishments that will be inspected by the fire marshal.

Communicate to the owners of pressure vessels, mechanical
contractors, engineering consulting companies, and insurance
companies doing business in Kentucky that used pressure vessels are not exempt from registration and initial inspection before being placed in service in Kentucky.

Effectively participate in the National Fire Protection Association’s standard development process to develop guidance on the safe disposal of fireworks, as recommended under recommendation 2011-06-I-HI-R7.

Establish formal policy requiring that: • Solicitations for contracts dealing with the storage, handling, and disposal of explosive hazardous materials, including fireworks, incorporate rigorous safety-related contractor selection provisions such as those provided in the DoD’s Contractor’s Safety Manual for Ammunition and Explosives, Section C1.5, “Pre-Award Safety Survey”; and • Contracts dealing with the storage, handling, and disposal of explosive hazardous materials, including fireworks, include a provision requiring that any subcontract (regardless of tier) for the storage, handling, and disposal of explosives (including fireworks) be selected based on rigorous safety-related contractor selection provisions such as those provided in the DOD's Contractor Safety Manual for Ammunition and Explosives, Section C1.5, "Pre-Award Safety Survey."

When the NFPA guidance developed by the National Fire Protection Association for the safe disposal of fireworks as recommended under recommendation 2011-06-I-HI-R7 is completed, incorporate this document by reference into the formal policies established by 2011-06-I-HI-R2 and 2011-06-I-HI-R3.

Revise the Resource Conservation and Recovery Act (RCRA) Subtitle C regulations to require a permitting process with rigorous safety reviews to replace the use of emergency permits under 40 CFR §270.61 for the disposal of explosive hazardous materials, including fireworks. At a minimum, the new process should require the use of best available technology, safe disposal methodologies, as well as safety management practices, such as those required by OSHA’s Process Safety Management Standard (PSM), 29 CFR §1910.119 (e.g., hazard analysis and control, management of change).

Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.

2011-06-I-HI-10

Until recommendation 2011-06-I-HI-R9 can be implemented, develop and issue a policy guidance document to provide a regulatory process with rigorous safety reviews to replace the use of emergency permits under 40 CFR §270.61 for the disposal of explosive hazardous materials, including fireworks. At a minimum, the new process should require the use of best available technology, safe disposal methodologies, as well as safety management practices, such as those required by OSHA’s Process Safety Management Standard (PSM), 29 CFR §1910.119 (e.g., hazard analysis and control, management of change). Ensure its effective communication to all EPA regional administrators, state environmental agencies, and organizations within the fireworks industry

Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.

2011-06-I-HI-11

Effectively participate in the National Fire Protection Association’s standard development process to develop guidance on the safe and environmentally sound disposal of fireworks, as recommended under recommendation 2011-06-I-HI-R7. Status

Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.

Establish an additional contractor responsibility determination requirement under Subpart 9.104-1 of the Federal Acquisition Regulation (FAR) addressing contractor safety performance. The analysis under this requirement should focus on incident prevention, and environmental and system safety. At a minimum, the language should specifically require the review of a prospective contractor’s: • Environmental and safety programs; • Safety record and incident history; • Ability to use safe methods for any work involving hazardous materials (including explosives); and • Suitable training and qualifications for the personnel involved in the work including prior relevant safety experience.

Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.

Develop a new standard, or incorporate within an existing standard, best practices for the safe disposal of waste fireworks that are consistent with environmental requirements. At a minimum this guidance or standard should: • Discourage the disassembly of waste fireworks as a step in the disposal process; • Minimize the accumulation of waste explosive materials, and encourage practices that reduce, recycle, reuse,or repurpose fireworks; and • Incorporate input from ATF, EPA, and other agencies, experts, and available resources on fireworks disposal methodologies.

Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.

2011-06-I-HI-8

Once fireworks disposal best practices under recommendation 2011-06-I-HI-R7 is completed, develop and implement an outreach plan to promptly communicate the new NFPA practices to relevant government agencies and private entities that dispose of waste fireworks

Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.

Require additional provisions within the TEOAF seized property management contract, such as a contract line item number (CLIN), that provide for the prime contractor to use expert(s) to assist the prime contractor’s personnel in the selection and oversight of subcontractors who handle, store, or dispose of explosive hazardous materials, including fireworks, pursuant to the main contract.

Open - Unacceptable Response/No Response Received (O - UR) - Recipient responds by expressing disagreement with the need outlined in the recommendation. The Board believes, however, that there is enough supporting evidence to ask the recipient to reconsider.

Work with the Association of Hose and Accessories Distributors (NAHAD) and chlorine hose manufacturers, such as Crane-Resistoflex, to develop and implement a recommended practice requiring continuous positive identification (e.g., coding, stenciling, stamping) throughout the supply chain, from manufacturing to the end user of the product.

Revise the mechanical integrity program:
Develop and implement a quality assurance management system, such as positive
materials identification, to confirm that chlorine transfer hoses (CTH) are of the
appropriate materials of construction.

Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.

2002-04-I-MO-2

Revise the mechanical integrity program:
Implement procedures and practices to ensure the emergency shutdown (ESD) system operates properly. Include procedures to verify that the ESD valves will close to shut down the flow of chlorine.

Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.

2002-04-I-MO-3

Revise the mechanical integrity program:
Revise the preventive maintenance and inspection program for the chlorine transfer
system to address moisture-related corrosion. Evaluate and correct any problems
associated with corrosion that could potentially lead to chlorine transfer and safety
system failure.

Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.

2002-04-I-MO-6

Revise the Emergency Response Plan:
Develop and implement a timetable for drills to test emergency response personnel on various levels of response, including a large uncontrolled release that could affect the public. Coordinate these drills with local emergency response authorities. Provide a copy of the revised Emergency Response Plan to the local emergency planning
committee, and review the plan with the committee and the local fire department. Work with these authorities to implement an improved community emergency notification system.

In light of the findings of this report, conduct periodic audits of the safety management systems involved in this incident, such as mechanical integrity, emergency response, and material quality assurance. Ensure that the audit recommendations are tracked and implemented. Share findings and recommendations with the work force at your repackaging facilities.

In collaboration with appropriate agencies, hold a community meeting in Festus, Missouri, to hear concerns raised by local citizens affected by the DPC incident and to respond to issues raised by the community.

Work with The Chlorine Institute and chlorine hose manufacturers, such as Crane-Resistoflex, to develop and implement a recommended practice requiring continuous positive identification (e.g.,coding, stenciling, stamping) throughout the supply chain, from manufacturing to the end user of the product.

Clarify the chemistry involved in over-chlorination incidents so that "Chlorine Scrubbing Systems, Pamphlet 89," and other pertinent publications: -Ensure that the recommended practices and safeguards prevent, mitigate, and control hazardous releases due to bleach decomposition. -Provide sufficient detail on the safety and environmental consequences of over-chlorination to enable companies to provide emergency responders with information on the potential characteristics of over-chlorination events, and on the best means of mitigating the bleach decomposition reaction following a release.

Establish and implement DPC corporate engineering standards that include adequate layers of protection on chlorine scrubbers at DPC facilities, including: -additional interlocks and shutdowns, such as automatically stopping chlorine flow to the scrubber upon oxidation-reduction potential alarm; -mitigation measures, such as systems to automatically add caustic to over-chlorinated scrubbers, or back-up scrubbing capability to treat emissions from over-chlorinated scrubbers; -increases in the final caustic concentration in the scrubbers to eight percent or higher to provide a substantial safety margin against over-chlorination; and -use of the site's continuous bleach manufacturing system to convert scrubber solution to saleable bleach.

Revise scrubber SOPs to include: -clearly described operating limits and warnings about the consequences of exceeding those limits, and -the safety and environmental hazards associated with scrubber over-chlorination.

Include scrubber operation in facility PHAs. Ensure that they: -include lessons learned from this incident and other DPC scrubber incidents, as well as industry experience with over-chlorination, and -consider off-site consequences when evaluating the adequacy of existing safeguards.

Implement a recognized safety management system, including third party verification and certification, to achieve documented continuous improvement in safety performance at Glendale and the other DPC chlorine repackaging sites.

Work with the Glendale Police Department to integrate them into the incident command structure during hazardous material incidents, and address communications issues, such as radio interoperability, to ensure the timely transmission of critical safety information to responding officers.

Work with the Glendale Fire Department to integrate the Glendale Police Department into the command structure during hazardous material incidents, and address communications issues, such as radio interoperability, to ensure the timely transmission of critical safety information to responding officers.

Closed - Acceptable Action (C - AA) - The recipient has completed action on the recommendation. The action taken meets the objectives envisioned by the Board.

2004-2-I-AZ-10

Ensure that police officers responding to hazardous material incidents are briefed on specific incident conditions, and are equipped with and trained on the proper use, capabilities, and limitations of appropriate protective equipment.

Revise DPC's permitted operating conditions to specify a minimum scrubber caustic concentration of 8 percent or more, as determined by laboratory measurement, with measurements taken daily and upon completion of each scrubber batch.

Open - Awaiting Response or Evaluation/Approval of Response (O - ARE/AR) - The recipient has not submitted a substantive response, or the evaluation by CSB staff of a response is pending, or the Board has not yet acted on staff recommendation of status.

Revise the facility emergency response protocol to require that a responsible and accountable DuPont employee always be available (all shifts, all days) to provide timely and accurate information to the Kanawha County Emergency Ambulance Authority (KCEAA) and Metro 9-1-1 dispatchers.

Requiring that all indoor phosgene production and storage areas, as defined in NFPA 55, have secondary enclosures, mechanical ventilation systems, emergency phosgene scrubbers, and automated audible alarms, which are, at a minimum, consistent with the standards of NFPA 55 for highly toxic gases.

Prohibiting the use of hoses with permeable cores and materials susceptible to chlorides corrosion for phosgene transfer.

Conducting annual phosgene hazard awareness training for all employees who handle phosgene, including the hazards associated with thermal expansion of entrapped liquid phosgene in piping and equipment.

Review all DuPont units that produce and handle phosgene that, at a minimum, observe and document site-specific practices for engineering controls, construction materials, PPE, procedures, maintenance, emergency response, and release detection and alarms, and use information from external sources to develop and implement consistent company-wide policies for the safe production and handling of phosgene.